A recent expansion of the federal “public charge” rule allows the government to deny immigrants permanent residency based on their income or health status or if they participate in programs that did not previously trigger the rule, such as Medicaid or the Supplemental Nutritional Assistance Program [SNAP]. Critics contend that this will dissuade individuals from participating in programs or obtaining medical care. In this JAMA Network Open paper, Benjamin D. Sommers, Heidi Allen, Aditi Bhanja, Robert J. Blendon, John Orav, and Arnold M. Epstein examine perceptions of the new public charge rule and its potential impacts on public program participation and medical care among low-income adults in Texas.


The research team conducted a telephone survey in November and December, 2019 of 19-64 year-old U.S. citizens in Texas with family incomes below 138 percent of the federal poverty level. They found:

  • 59 percent of respondents had heard of the changes to the public charge rule; 45 percent of those were concerned about the policy’s impact on family and friends.
  • 12 percent reported knowing friends or family who had avoided participating in Medicaid, SNAP, or public housing, or not visited a doctor or hospital because of immigration-related concerns in the past year.
  • The most common outcome was avoiding medical care (8 percent); for nearly all programs, the majority said these changes were a “serious problem.”
  • Awareness of the rule was lower among young adults, rural residents, and people with chronic conditions; Latino, black and urban residents more often knew friends or family who avoided public programs than did white and rural residents.

Implications for Policy and Practice

These findings are consistent with recent reports in Texas on reductions in Medicaid enrollment linked to immigration concerns, and national estimates that 3 million people may forego health insurance because of the public charge rule. Furthermore, 22 million U.S. citizens live in mixed-status households with at least one non-citizen household member. Thus, the “chilling effects” of this new rule are potentially far-reaching and are even more concerning in the context of the current COVID-19 pandemic.